A weblink related to a recent UHC financing forum in Washington DC (hosted by the World Bank) caught my attention a few weeks ago. The (PR) picture in the article featured health workers handling newborns placed head-to-head in what appears to be a routine setting. All seems peaceful and nice, but from a technical standpoint, the picture actually shouts “nightmare!” to any person working on maternal and child health (MCH). (Common guys, we are trying to undo this!) Among other potential harms, unnecessary separation of newborns from their mothers affects breastfeeding outcomes.
(By now, you probably have a hunch that I feel strongly about breastfeeding, so in this short piece I will indeed talk about breastfeeding, one of the most polarizing topics on the planet. Don’t leave yet, Hans Rosling and Adele will come later!)
Breastmilk is now likened to personalized medicine. But any breastfeeding is not the same as meeting optimal standards. Delaying breastfeeding initiation, even by an hour, increases the risk of death (seriously!). Mix-feeding newborns with formula inhibits breastmilk’s protective effect against serious illness. WHO recommends mothers to 1) breastfeed within the first hour of birth 2) exclusively breastfeed for 6 months, without giving any water or food and 3) continue breastfeeding up to two years or beyond, with addition of appropriate foods.
This standard is not easy to meet. Ask your mother. Or ask a friend with a kid. Ask health systems.
In low and middle income countries, only 37% of children are exclusively breastfed for the first six months. In the 2013 DHS survey, a region in the Philippines reported 68.3% facility-based deliveries, yet only 26% of their newborns were breastfed within an hour of birth! How can we fail to deliver human milk – a universally prepositioned, no-cost (FREE!) and potent intervention – in a timely manner? There is clearly a need to look into the more complicated aspects of breastfeeding support.
The situation in developed countries isn’t all that different. In a US study, two-thirds of mothers did not meet their own breastfeeding goal. No wonder people are offended when the issue is discussed. After the recent sugar tax victory in the UK, celebrity chef Jamie Oliver turned his attention to breastfeeding, earning the ire of mothers including pop icon Adele who even mentioned that formula is “just as good” as breastmilk. (Not a smart idea for men to wade into risky female territory, some of you might say, but see below for more on why breastfeeding shouldn’t just be the mother’s responsibility.)
What if mothers do not breastfeed? Mounting evidence links (not) breastfeeding to current global threats: obesity, diabetes and certain cancers (Are we missing out on an early modifiable risk factor?). Globally, breastfeeding averts 823,000 child deaths under the age of five and 20,000 deaths due to breast cancer. In Southeast Asia, it can prevent 50% (as in, five-zero!) of child deaths due to diarrhoea and pneumonia and 10% of deaths due to breast cancer. Not breastfeeding costs society $302 billion annually, which is 0.49% of the world’s gross income.
Does formula really measure up to breastmilk? Breastmilk components are complex and dynamic. For example, breastmilk supplies essential fats to the human brain at a crucial growth phase, reflecting on cognitive outcomes and earning potential in adult life. (Uh-oh, I was also not optimally breastfed... I could have been an ITM PhD student by now!) Formula is modified cow’s milk and will never have specificity for immune protection and human nourishment.
While advocates argue about the relative silence on formula risks, they also challenge the current discourse: human milk is not better, rather formula is suboptimal; breastmilk does not reduce health risks, rather it allows infants to survive and thrive. This perspective shift is needed, BUT must be met with responsive systems that support and protect those who choose to breastfeed. Otherwise we will only terrorize mothers towards failure. Breastfeeding is not exactly a serene experience. If interventions are not appropriately and timely delivered, it requires huge effort and can even be painful, both physically and emotionally. (I know, having been through it, with postpartum depression and all)
The good news is, breastfeeding rates respond to interventions. However, there is underinvestment to deliver protection and support at the health system level. Health systems promote that “breastfeeding is best” but often, mothers are left on their own to figure out how to do so as many countries still struggle to scale up interventions that work.
We place huge pressure on mothers to succeed, but many determinants are beyond the mother’s control. Rising labour force participation among women and poor workplace maternity protection makes optimal breastfeeding inconvenient, if not impossible. (Hey, I am not saying mothers be forced to stay at home to breastfeed. Societies should instead recognize their unique contribution and support them in the workplace!) Unethical marketing facilitates the wrong impression that formula is a suitable, if not an equal alternative. Hence, many perceive breastfeeding as a lifestyle choice, resulting in a tension with health system goals.
The formula industry presents another important “challenge”. The industry continues to push its agenda despite the International Code of Marketing of Breast-milk Substitutes in place. One sly strategy is to hijack the global nutrition community’s focus on the first 1000 days of life – from pregnancy to a child’s second birthday. In 2012, Nestle quietly succeeded in registering “THE FIRST 1000 DAYS” as their property in the Global Brand Database of Mexico and the Philippines (key in “1000 days” on the weblink). Furthermore, these companies discreetly engage in high level health system forums on the global scene and in national settings. (They are in fact so discreet, that I cannot give you a link to prove this. But some of my compatriots surely know what event I’m referring to)
Let us go back to health systems. In a video, the famous Dr Hans Rosling illustrates financial protection through a Cambodian couple just rising out of poverty. Anticipating twins, the woman delivered in the hospital. Thanks to a financial protection scheme they return home, mother and twins safe, the family spared from the catastrophic costs of hospitalization. But eek… the mother was already formula feeding at the hospital (44:30)!
A single diarrhoea episode is enough to bring these babies back to the hospital. A few more days and the family runs out of money for formula. By that time, normal breastfeeding processes have been sabotaged and it will be a challenge for both mother and babies to return to the breast. The mother will then say that she tried, but she does not have milk. Like so many, many mothers around the world.
An alternative picture is a mother empowered to make an informed decision knowing that with skilled measures and support, her body can ensure adequate breastmilk for the twins. Mothers and babies at high risk for breastfeeding failure often require support beyond routine care. But even routine messages and skills are often unrecognized or not taught properly to health workers. The situation is more depressing for mothers and babies in man-made crises and natural disasters, where resources are scarce and conditions are unhygienic.
Dr Rosling’s video manifests a blind spot we have as a global community. When populations are not covered by optimal breastfeeding interventions, infants succumb to disease or malnutrition, throwing away health system gains. Promoting breastfeeding without responsive systems that protect and support those who choose to breastfeed is unacceptable. Strategies should be embedded in society and health systems to reach mothers in an acceptable, timely and equitable way. As colleagues in nutrition and child health build momentum for breastfeeding, let us all move with them towards the same direction. (I think we can even ask Jamie Oliver to join us, but he will have to read all weblinks in this article first. Alternatively, he could go for a VR breastfeeding experience, that will surely also get him on the same page 🙂 )